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Request for refund (Select for Instructions)

Needs to be submitted with a copy of the WPS Explanation of Benefits (EOB) to: WPS/TRICARE For Life P.O. Box 7928 Madison, WI 53707-7928.

Refund Information Request Instructions

Tax Identification Number (TIN) - Provider’s nine digit Tax ID. Please complete separate refunds forms for different Tax ID’s.

Patient Name - Patient’s name as it appears on the TRICARE Explanation of Benefits.

Sponsor Number - Policyholder’s social security number.

Claim Number - Claim number as it appears on the TRICARE Explanation of Benefits.

Begin Date of Service - Earliest date of service on each claim.

Reason for Refund - Please select a reason from the drop down that best describes the overpayment.

  • Medicare Adjustment/Reversal – Attach the corrected Explanation of Benefits (EOB) from Medicare if available.
  • Wrong Payee – Please explain in comments.
  • Other Health Insurance Paid – Attach all EOB’s from the other health insurance and enter name of insurance in comments field.
  • Corrected Billing/Billed in Error –Attach corrected claim along with any EOB’s from the other health insurance.
  • Duplicate TRICARE Payment - Enter duplicate claim number in comments.
  • Patient Not Eligible – Attach any related documentation.

Overpaid Amount - The amount you determined is overpaid.

Comments - Any additional information.

Mail completed form(s) along with refund to:

TRICARE for Life
P.O. Box 7928
Madison, WI 53707-7928

Do not complete Refund Information Request form when refunding due to a recoupment request from TRICARE. Original letter of Recoupment should instead be attached to any refund.

RIRForm.xls | 80 KB